Which physical findings are characteristic of optic neuritis in multiple sclerosis (MS)?

Updated: Feb 21, 2019
  • Author: Fiona Costello, MD, FRCP; Chief Editor: Hampton Roy, Sr, MD  more...
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Answer

Answer

In patients with suspected optic neuritis, several features on initial examination can help localize the diagnosis. Initially, the severity of vision loss in the affected eye may range from mild (Snellen visual acuity equivalent of 20/20) to, in rare cases, no light perception with high-contrast letter acuity testing. [14] In patients with unilateral optic neuritis or bilateral optic neuritis with asymmetric involvement, a relative afferent pupillary defect (RAPD) is apparent in the affected or, in cases of bilateral involvement, more severely affected eye. [14] Visual field loss in optic neuritis tends to follow the topography of the retinal nerve fiber layer (RNFL), with cecocentral, altitudinal, and arcuate deficits frequently observed.

Keltner and colleagues [17] classified visual field abnormalities observed during longitudinal follow-up of patients with ONTT and reported that both the affected and fellow eyes in patients with optic neuritis showed visual field losses. [17] These findings illustrated the role of perimetry in detecting both clinically overt and clinically occult optic nerve involvement in patients with MS.

Dyschromatopsia, or decreased color vision, is typical in eyes with optic neuritis. [14] This finding can be particularly helpful in localizing the diagnosis in patients with mild central vision loss who have disproportionate deficits in color vision function. [14] Often, patients continue to note subjective color desaturation in their affected eyes after high-contrast visual acuity function has returned to a Snellen equivalent of 20/20.

Traditionally, in cases of retrobulbar optic neuritis, the optic nerve has been described as normal in appearance, whereas patients with anterior optic neuritis, or papillitis, present with mild to moderate optic disc swelling at presentation (see image below). [14] As was exemplified in the ONTT, severe optic disc edema, [18] vitreous cells, and/or hemorrhage are uncommon in the setting of typical optic neuritis. [14] Therefore, the observation of these fundus features should prompt investigation for other potential etiologies of vision loss.


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